Devoted DUAL PLUS Pennsylvania (HMO D-SNP)
Devoted DUAL PLUS Pennsylvania (HMO D-SNP) H6852-005 Plan Details
Devoted DUAL PLUS Pennsylvania (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Devoted Health
Plan ID: H6852-005
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$0.00
Monthly Premium
Devoted DUAL PLUS Pennsylvania (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Devoted Health
Plan ID: H6852-005
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Pennsylvania Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $9350 Out-of-Network: N/A |
| Initial Coverage Limit | $2000 |
| Catastrophic Coverage Limit | $2,000 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0 |
| Inpatient Hospital Care | Inpatient Hospital Coverage:
|
| Urgent Care | Coinsurance for Urgent Care 0% or 35% Worldwide Coverage: Copayment for Worldwide Urgent Coverage $0 |
| Emergency Room Visit | Copayment for Emergency Care $0 or $110 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $0 Copayment for Worldwide Emergency Transportation $0 |
| Ambulance Transportation | Ground Ambulance 35% deductible applies (INN) PA may be required (Medicaid covered: $0) Air or Water Ambulance 35% deductible applies (INN) PA may be required (Medicaid covered: $0) Facility to Facility Transfer Member will not be responsible for additional ground ambulance copays for facility to facility transfers. |
Health Care Services and Medical Supplies
Devoted DUAL PLUS Pennsylvania (HMO D-SNP) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | Chiropractic Services - Medicare Covered Copayment $0 Chiropractic Services - Routine Visits Copayment Not covered |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | Copayment for Medicare-covered Diabetic Supplies 20% PA may be required (Medicaid covered: $0) Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0 PA may be required |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20% Prior Authorization Required for Durable Medical Equipment Plan covers crutches with 20% coinsurance.The following DME has 20% coinsurance:Medicare-covered ventilator, Bone growth stimulator, Portable oxygen concentrator, Bariatric equipment, Specialty beds, Custom or specialty wheelchairs and scooters, Seat lifts, Specialty brand items, High Frequency Chest Compression Vests, Pain Infusion Pump, Continuous Glucose Monitor (other than Plan's preferred CGM), and Home Infusion Therapy (HIT) drugs.$0 copay for the Plan's preferred Continuous Glucose Monitor.20% coinsurance for all other DME. Prior authorization required |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Coinsurance for Medicare-covered Diagnostic Procedures/Tests 0% to 35% Coinsurance for Medicare-covered Lab Services 0% or 35% Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Copayment varies based on site of service:PCPs office: $0 copay for EKGs/EEGs/ECGs, $0 copay all other. Specialist office: $0 copay for EKGs/EEGs/ECGs, 35% coinsurance all other. Freestanding facility: 35% coinsurance for EKGs/EEGs/ECGs, 35% coinsurance all other. Outpatient hospital: 35% coinsurance for EKGs/EEGs/ECGs, 35% coinsurance all other. Outpatient Diag/Therapeutic Rad Services: Coinsurance for Medicare-covered Diagnostic Radiological Services 0% or 35% Coinsurance for Medicare-covered Therapeutic Radiological Services 0% or 20% Coinsurance for Medicare-covered X-Ray Services 0% or 35% Prior authorization required |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services Prior authorization required |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $0 or $1950 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $0 Copayment for Medicare-covered Group Sessions $0 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Coinsurance for Medicare Covered Outpatient Hospital Services 0% or 35% to 40% Prior Authorization Required for Outpatient Hospital Services 40% coinsurance for diagnostic colonoscopies, 35% coinsurance for all other outpatient hospital services. Outpatient Observation Services: Coinsurance for Medicare Covered Observation Services 0% or 35% Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Coinsurance for Ambulatory Surgical Center Services 0% or 35% to 40% Prior Authorization Required for Ambulatory Surgical Center Services 40% coinsurance for diagnostic colonoscopies, 35% coinsurance for all other ASC services. Prior authorization required |
| Outpatient Substance Abuse Care | In-Network: Coinsurance for Medicare-covered Individual Sessions 0% or 35% Coinsurance for Medicare-covered Group Sessions 0% or 35% |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $0 |
| Skilled Nursing Facility Care | 0 or $In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $214 per day for days 21 to 64 $0 per day for days 65 to 100 Prior Authorization Required for Skilled Nursing Facility Services Prior authorization required |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | This plan has a: Dental/Eyewear Card. Copayment for Medicare Covered Dental Services: $0 PA may be required Preventive & Comprehensive Dental Services: You have $500 per year towards Preventive Dental, Comprehensive Dental, and/or Eyewear combined. You can see any licensed dentist or visit any eyewear retailer. The $500 will be preloaded onto a debit card. You can use your card at any dental or eyewear provider who accepts MasterCard. Cosmetic procedures, dental implants, and/or elective procedures are not eligible. Please see Summary of Benefits and Evidence of Coverage for more benefit information. |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Eye Exams: Coinsurance for Medicare Covered Benefits 0% or 35% Copayment for Routine Eye Exams $0
Eyewear: Copayment for Medicare-Covered Benefits $0 Maximum Plan Allowance of $500 every year. Allowance may be combined with comprehensive dental benefits. Please see Summary of Benefits and Evidence of Coverage for more benefit information. |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Hearing Exams: Coinsurance for Medicare Covered Benefits 0% or 35% Copayment for Routine Hearing Exams $0
Hearing Aids: Copayment for Hearing Aids $0 to $299
|
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Preventive Services and Health/Wellness Education Programs | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit |
